Transcript of Y our P lan Explained 2020 - uhcretiree.com
2020 Your Plan Explained 12408Your Plan Explained 2020
Take advantage of all your Medicare Advantage plan has to
offer.
Connecticut State Retiree Health Plan Retired On or After October
2, 2017
UnitedHealthcare® Group Medicare Advantage (PPO)
Effective: January 1, 2020 through December 31, 2020
Group Number: 12408
COMPTROLLER
This is a short description of your 2020 plan benefits. For
complete information, please refer to your Summary of Benefits or
Evidence of Coverage. Limitations, exclusions, and restrictions may
apply.
Medical Benefits Benefits covered by UnitedHealthcare Group
Medicare Advantage (PPO)
In-Network and Out-of-Network
Doctor’s office visit Primary Care Provider: $15 copay Specialist:
$15 copay
Preventive services $0 copay for Medicare-covered preventive
services. Refer to the Summary of Benefits or Evidence of Coverage
for additional information.
Inpatient hospital care $0 copay per stay Skilled nursing facility
(SNF) $0 copay per stay Outpatient surgery $0 copay Outpatient
rehabilitation (physical, occupational, or speech/language
therapy)
$0 copay
$0 copay
Lab services $0 copay Outpatient x-rays $0 copay Therapeutic
radiology services (such as radiation treatment for cancer)
$0 copay
Ambulance $0 copay Emergency care $100 copay (worldwide) Urgently
needed services $15 copay (worldwide) Annual medical out-of-pocket
maximum
Your plan has an annual combined in-network and out-of-network
out-of-pocket maximum of $2,000 each plan year
Benefit Highlights Effective January 1, 2020 to December 31,
2020
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In-Network and Out-of-Network
Routine physical $0 copay; 1 per plan year Acupuncture $15 copay
(up to 20 visits per plan year) Chiropractic care $0 copay
(unlimited visits per plan year) Foot care – routine $15 copay (up
to 6 visits per plan year) Hearing – routine exam $15 copay (1 exam
every 12 months)
Hearing aids The plan pays an unlimited allowance towards 2 hearing
aids every 3 years. Hearing aid coverage under this plan is only
available through UnitedHealthcare Hearing Network.
Vision – routine eye exam $15 copay (1 exam every 12 months)
Naturopathic services – routine
You are covered for routine naturopathic services with $15 copay
(unlimited visits)
Private duty nursing $0 copay There is no visit limit per plan year
for private duty nursing services.
Fitness program through SilverSneakers®
$0 copay Stay active with a basic gym membership at a participating
location at no extra cost to you
NurseLine $0 copay Speak with a registered nurse (RN) 24 hours a
day, 7 days a week
Virtual behavioral visits
$15 copay See and speak to specific mental health professionals
using your computer or mobile device. Find participating mental
health professionals online at www.UHCRetiree.com/CT
Virtual doctor visits $0 copay See and speak to specific doctors
using your computer or mobile device. Find participating doctors
online at www.UHCRetiree.com/CT
* We only cover Accu-Chek® and OneTouch® brands. OneTouch Verio®
Flex, Accu-Chek® Guide Me, Accu-Chek® Guide, and Accu-Chek® Aviva
Plus. Test strips: OneTouch Verio®, OneTouch Ultra®, Accu-Chek®
Guide, Accu-Chek® Aviva Plus, Accu-Chek® SmartView, and Accu-Chek®
Compact Plus.
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Prescription Drugs Initial Coverage Stage Network Retail and
Mail Service Pharmacy (up to a 90-day supply)
Preferred Retail and Mail Service Pharmacy (up to a 90-day supply
of lower cost drugs to treat certain conditions)†≠
Tier 1 – Preferred Generic
$5 copay $0 copay
Tier 3 – Non-preferred Drug
$40 copay $12.50 copay
Tier 4 – Specialty Tier $40 copay $12.50 copay
Coverage gap stage After your total drug costs reach $4,020, the
plan continues to pay its share of the cost of your drugs and you
pay your share of the cost.
Catastrophic coverage stage
When your total out-of-pocket costs for Part D prescription drugs
reach $6,350 you will pay a $0 copay for your drugs for the rest of
the plan year
† Please see the Additional Drug Coverage for a list of lower cost
drugs to treat these conditions: asthma or COPD, heart
disease/heart failure, hypertension and cholesterol.
≠Reduced copay only available at Preferred Retail Pharmacy and Mail
order.
Your plan sponsor has elected to offer additional coverage on some
prescription drugs that are normally excluded from coverage on your
drug list (formulary). Please see your Additional Drug Coverage
list for more information.
Plans are insured through UnitedHealthcare Insurance Company or one
of its affiliated companies, a Medicare Advantage organization with
a Medicare contract. Enrollment in the plan depends on the plan’s
contract renewal with Medicare. Retiree plan prospects must meet
the eligibility requirements to enroll for group coverage. The
benefit information provided is a brief summary, not a complete
description of benefits. For more information, contact the plan.
Limitations, copays, and restrictions may apply. Medicare
requirements may change each plan year based on Medicare
guidelines. Y0066_BH_H2001_847_000_2020_Plan5_M
UHEX20PP4518278_000
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UnitedHealthcare® Group Medicare Advantage (PPO)
The Connecticut State Retiree Health Plan will provide coverage
through the UnitedHealthcare® Group Medicare Advantage plan. This
is a custom Group Medicare Advantage plan designed at the direction
of the Health Care Cost Containment Committee exclusively for State
retirees to deliver the State Health Plan benefits.
“Medicare Advantage” is also known as Medicare Part C. These plans
have all the benefits of Medicare Part A (hospital coverage) and
Medicare Part B (doctor and outpatient care) plus extra programs
that go beyond Original Medicare (Medicare Parts A and B). In
addition, this Group Medicare Advantage plan includes Medicare Part
D prescription drug coverage.
Medicare Advantage coverage
Extra Programs Beyond Original
Medicare Part D Prescription drugs
You must be entitled to Medicare Part A (if applicable) and
enrolled in Medicare Part B to enroll in this plan. If you are not
entitled to Medicare Part A, please refer to your plan sponsor’s
enrollment materials or contact your plan sponsor directly to
determine if you are eligible to enroll in our plan. • If you’re
not sure if you are enrolled in Medicare Part B, check with
Social Security. Visit www.ssa.gov/locator or call 1-800-772-1213,
TTY 1-800-325-0778, between 7 a.m. – 7 p.m. local time, Monday –
Friday.
• You must continue paying your Medicare Part B premium to keep
your coverage under this group-sponsored plan. If you stop your
payments, you may be disenrolled from this plan. The State of
Connecticut will continue to reimburse your Medicare Part B and, if
applicable, Part D premiums in your pension check.
Make sure you know what parts of Medicare you have
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How your Group Medicare Advantage plan works Here are Medicare’s
rules about what types of coverage you can add or combine with a
group-sponsored Medicare Advantage plan.
One plan at a time • You may be enrolled in only one Medicare
Advantage plan and one Medicare Part D
prescription drug plan at a time. This Connecticut State Retiree
Health plan combines your Medicare Advantage and Medicare Part D
prescription drug coverage into one plan.
• The plan you enroll in last is the plan that Centers for Medicare
& Medicaid Services (CMS) considers to be your final
decision.
• If you enroll in another Medicare Advantage plan or a stand-alone
Medicare Part D prescription drug plan after your enrollment in the
Connecticut State Retiree Health Plan, you will be disenrolled from
this UnitedHealthcare® Group Medicare Advantage (PPO) plan.
• If you are the retiree, your dependents will also be disenrolled,
which means that you and your family may not have hospital/medical
or drug coverage through the Connecticut State Retiree Health
Plan.
UHEX20PP4477870_000 SPRJ48399
Remember: If you drop or are disenrolled from the Connecticut State
Retiree Health Plan, you may not be able to re-enroll in this plan
until the following enrollment period.
Visit us online anytime www.UHCRetiree.com/CT Toll-free
1-888-803-9217, TTY 711,
8 a.m. – 8 p.m. local time, Monday – Friday
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How your medical coverage works Your plan is a Preferred Provider
Organization (PPO) plan. You have access to our nationwide
coverage. You can see any provider (in-network or out-of-network)
at the same cost share, as long as they agree to see you and have
not opted out of or been excluded from Medicare.
In-Network Out-Of-Network
Can I continue to see my doctor/specialist? Yes
Yes, as long as they participate in Medicare and accept the
plan.1
What is my copay? Copays vary by service.2
Do I need to choose a primary care provider (PCP)? No, but
recommended. No, but recommended.
Do I need a referral to see a specialist? No No
Can I go to any hospital? Yes Yes, as long as they participate in
Medicare and accept the plan.1
Are emergency and urgently needed services covered? Yes Yes
Do I have to pay the full cost for all doctor or hospital services?
You will pay your standard copay for the services you get.2
Is there a limit on how much I spend on medical services each
year?
Yes2 Yes2
Are there any situations when a doctor will balance bill me?
Under this plan, you are not responsible for any balance billing
when seeing health care providers who have not opted out of
Medicare.
1 This means that the provider or hospital agrees to treat you and
be paid according to UnitedHealthcare’s payment schedule. With this
plan, we pay the same as Medicare and follow Medicare’s rules.
Emergencies would be covered even if out-of-network.
2Refer to the Summary of Benefits or Benefit Highlights in this
guide for more information.
Once you receive your UnitedHealthcare Member ID card, you can
create your secure online account at: www.UHCRetiree.com/CT You’ll
be able to view plan documents, find a provider, locate a pharmacy
and access lifestyle and learning articles, recipes, educational
videos and more.
View your plan information online
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What will I pay for my prescription drugs? What you pay will depend
on the coverage established by the State of Connecticut and on what
drug cost tier your prescription falls in to. Your cost may also
change during the year based on the total cost of the prescriptions
you have filled.1
How your prescription drug coverage works Your Medicare Part D
prescription drug coverage includes thousands of brand name and
generic prescription drugs. Check your plan’s drug list to see if
your drugs are covered.
1 To learn more about your coverage, please refer to your Benefit
Highlights or your Summary of Benefits.
What pharmacies can I use? You can choose from over 67,000 national
chain, regional and independent local retail pharmacies.
What is a drug cost tier? Drugs are divided into different cost
levels, or tiers. In general, the lower the tier, the less you
pay.
Can I have more than one prescription drug plan? No. You can only
have one Medicare plan that includes prescription drug coverage at
a time. If you enroll in another Medicare Part D prescription drug
plan OR a Medicare Advantage plan that includes prescription drug
coverage, you will be disenrolled from this plan.
Here are answers to common questions
Visit us online anytime www.UHCRetiree.com/CT Toll-free
1-888-803-9217, TTY 711,
8 a.m. – 8 p.m. local time, Monday – Friday
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Ways to save on your prescription drugs
You may save on the medications you take regularly If you prefer
the convenience of mail order, you could save time and money by
receiving your maintenance medications through OptumRx® Home
Delivery. You’ll get automatic refill reminders and access to
licensed pharmacists if you have questions.
Get a 3 month1 supply at retail pharmacies In addition to OptumRx®
Home Delivery, most retail pharmacies offer 3 month supplies for
some prescription drugs. Check your UnitedHealthcare pharmacy
directory to see if a retail pharmacy offers 3 month supplies noted
with a symbol. An online pharmacy directory is available at:
www.UHCRetiree.com/CT To request a printed directory, call Customer
Service toll-free at:
1-888-803-9217, TTY 711, 8 a.m. – 8 p.m. local time, Monday –
Friday
Ask your doctor about trial supplies A trial supply allows you to
fill a prescription for less than 30 days. This way you can pay a
reduced copay and make sure the medication works for you before
getting a full month’s supply.
Explore lower cost options Each covered drug in your drug list is
assigned to a drug cost tier. Generally, the lower the tier, the
less you pay. If you’re taking a higher-tier drug, you may want to
ask your doctor if there’s a lower-tier drug you could take
instead.
Have an annual medication review Take some time during your Annual
Wellness Visit to make sure you are only taking the drugs you
need.
1 Your former employer or plan sponsor may provide coverage beyond
3 months. Please refer to the Benefit Highlights or Summary of
Benefits for more information.
UnitedHealthcare is committed to keeping your prescription drug
costs down. As a UnitedHealthcare member, you have our Savings
Promise that you’ll get the lowest price available. That low price
may be your plan copay, the pharmacy’s retail price or our
contracted price with the pharmacy.
The UnitedHealthcare Savings Promise
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What is IRMAA? The Income-Related Monthly Adjustment Amount (IRMAA)
is an amount Social Security determines you may need to pay if your
modified adjusted gross income on your IRS tax return from two
years ago is above a certain limit. This extra amount is paid
directly to Social Security, not to your plan. Social Security will
contact you if you have to pay IRMAA.
Call Social Security to see if you qualify for Extra Help
Toll-free call 1-800-772-1213, TTY 1-800-325-0778, between 7 a.m. –
7 p.m. local time, Monday – Friday
If you have a limited income, you may be able to get Extra Help to
pay for your prescription drug costs. If you qualify, Extra Help
could pay up to 75% or more of your drug costs. Many people qualify
and don’t know it. There’s no penalty for applying, and you can
re-apply every year.
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Your care begins with your doctor With this plan, you have the
flexibility to see doctors inside or outside the UnitedHealthcare
network. Even though it’s not required it’s important to have a
primary care provider. Unlike most PPO plans, with this plan, you
pay the same share of cost in- and out-of-network as long as they
participate in Medicare and accept the plan. With your
UnitedHealthcare® Group Medicare Advantage plan, you’re connected
to programs, resources, tools and people that can help you live a
healthier life.
Finding a doctor is easy If you need help finding a doctor or a
specialist, just give us a call. We can even help schedule that
first appointment.
Why use a UnitedHealthcare network doctor? We work closely with our
network of doctors to give them access to resources and tools that
can help them work with you to make better health care
decisions.
Filling your prescriptions is convenient UnitedHealthcare has over
67,000 national chain, regional and independent local retail
pharmacies in our network.1
Getting the health care coverage you may need
12019 Internal Report Data
8 a.m. – 8 p.m. local time, Monday – Friday
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Take advantage of UnitedHealthcare’s additional support and
programs
Annual Wellness Visit1 and many preventive services at $0 copay An
Annual Wellness Visit with your doctor is one of the best ways to
stay on top of your health. Together, with your doctor, you can
identify the preventive screenings you may need, review your
medications and talk about any health concerns. You may even get a
reward for completing your Annual Wellness Visit.
Enjoy a preventive care visit in the privacy of your own home With
UnitedHealthcare® HouseCalls, you get a yearly in-home visit from
one of our health care practitioners at no extra cost. A HouseCalls
visit is designed to support, but not take the place of your
regular doctor’s care. What to expect from a HouseCalls visit: • A
knowledgeable health care practitioner will review your health
history and current
medications, perform health screenings, help identify health risks
and provide health education
• You can talk about health concerns and ask questions that you
haven’t had time to ask before
• HouseCalls will send a summary of your visit to you and your
primary care provider so they have this additional information
regarding your health
HouseCalls may not be available in all areas.
You are never alone with NurseLine Health questions can come up
anytime. NurseLine provides you 24/7 access to a registered nurse
who can help you with sudden health concerns as well as: •
Questions about a medication • Finding a doctor or specialist •
Understanding an ongoing health condition or new diagnosis
Virtual Visits See a doctor or a Behavioral Health specialist using
your computer, tablet or smartphone. With Virtual Visits, you’re
able to live video chat from your computer, tablet or smartphone —
anytime, day or night. You will first need to register and then
schedule an appointment. On your tablet or smartphone you can
download the Doctor on Demand or Amwell apps.
Virtual Doctor Visits You can ask questions, get a diagnosis, or
even get medication prescribed and have it sent to your pharmacy.
All you need is a strong internet connection.
Virtual Doctor Visits are good for minor health concerns
like:
• Allergies, bronchitis, cold/cough
• Migraines/headaches, sinus problems, stomachaches
• Bladder/urinary tract infections, rashes
1If additional tests are required, there may be a copay or
coinsurance.
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Virtual Behavioral Health Visits Virtual Behavioral Health Visits
may be best for: • Initial evaluation • Medication management •
Addiction • Depression • Trauma and loss
• Stress or anxiety
Special programs for people with chronic or complex health needs
UnitedHealthcare offers special programs to help members who are
living with a chronic disease, like diabetes or heart disease. You
get personal attention and your doctors get up-to-date information
to help them make decisions.
Make caring for a loved one easier At no additional cost, Solutions
for Caregivers supports you, your family and those you care for by
providing information, education, resources and care planning. •
Get helpful advice and assistance finding services and programs
from a professional
care manager • Receive a personalized care plan with
recommendations and resources
• Have a registered nurse perform an in-person assessment of your
situation if needed
Hear the moments that matter most with custom-programmed hearing
aids Your hearing health is important to your overall well-being
and can help you stay connected to those around you. With
UnitedHealthcare Hearing, you’ll get access to receive a hearing
exam and a wide selection of custom-programmed hearing aids —
available in-person at any of our 5,000 UnitedHealthcare Hearing
providers nationwide* or through home delivery — so you’ll get the
care you need to hear better and live life to the fullest.
Other hearing exam providers are available in our network. Hearing
aid coverage under this plan is only available through
UnitedHealthcare Hearing.
And so much more to help you live a healthier life After you become
a member, we will connect you to many programs and tools that may
help you on your wellness journey. You will get information soon
after your coverage becomes effective.
*2019 UnitedHealthcare Internal Data
Tools and resources to put you in control
Get valuable plan information online As a UnitedHealthcare member,
you will have access to a safe, secure website where you’ll be able
to: • Look up your latest claim information • Review benefit
information and plan materials • Print a temporary member ID card
and request a new one • Search for network doctors • Search for
pharmacies • Look up drugs and how much they cost under your plan •
Learn more about health and wellness topics and sign up for healthy
challenges based
on your interests and goals
• Sign up to get your Explanation of Benefits online
Get active and have fun with a gym membership Designed for all
fitness levels and abilities, SilverSneakers® includes: • Access to
exercise equipment • Group classes and more at 16,000+ fitness
locations1
• Signature classes led by certified instructors trained
specifically in adult fitness Classes, equipment, facilities and
services may vary by location.
Go beyond the plan benefits to help you live your best life We all
want to live a healthier, happier life and Renew by
UnitedHealthcare can be your guide.2 Renew, our member-only Health
& Wellness Experience, includes: • Inspiring lifestyle tips,
coloring pages, recipe library, streaming music • Interactive
quizzes & tools • Learning courses, health news, articles &
videos, health topic library • Rewards As a UnitedHealthcare member
you can explore all that Renew has to offer by logging in to your
member website.
1 At-home kits are offered for members who want to start working
out at home or for those who can’t get to a fitness location due to
injury, illness or being homebound.
2Renew by UnitedHealthcare is not available in all plans.
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UHEX20PP4479639_000
Required Information Plans are insured through UnitedHealthcare
Insurance Company or one of its affiliated companies, a Medicare
Advantage organization with a Medicare contract and a
Medicare-approved Part D sponsor. Enrollment in the plan depends on
the plan’s contract renewal with Medicare. UnitedHealthcare
Insurance Company complies with applicable Federal civil rights
laws and does not discriminate on the basis of race, color,
national origin, age, disability, or sex. ATENCIÓN: si habla
español, tiene a su disposición servicios gratuitos de asistencia
lingüística. Llame al 1-888-803-9217 (TTY: 711). 1-888-803-9217
(TTY: 711). This information is not a complete description of
benefits. Contact the plan for more information. Limitations,
copayments, and restrictions may apply. Drugs and prices may vary
between pharmacies and are subject to change during the plan year.
Prices are based on quantity filled at the pharmacy. Quantities may
be limited by pharmacy based on their dispensing policy or by the
plan based on Quantity Limit requirements; if prescription is in
excess of a limit, copay amounts may be higher. Other pharmacies
are available in our network. Members may use any pharmacy in the
network, but may not receive Pharmacy Saver pricing. Pharmacies
participating in the Pharmacy Saver program may not be available in
all areas. You are not required to use OptumRx home delivery for
your maintenance medication. If you have not used OptumRx home
delivery, you must approve the first prescription order sent
directly from your doctor to OptumRx before it can be filled. New
prescriptions from OptumRx should arrive within ten business days
from the date the completed order is received, and refill orders
should arrive in about seven business days. Contact OptumRx anytime
at 1-888-279-1828, TTY 711. OptumRx is an affiliate of
UnitedHealthcare Insurance Company. The Formulary, pharmacy
network, and/or provider network may change at any time. You will
receive notice when necessary. Out-of-network/non-contracted
providers are under no obligation to treat UnitedHealthcare
members, except in emergency situations. Please call the customer
service number or see your Evidence of Coverage for more
information. Solutions for Caregivers assists in coordinating
community and in-home resources. The final decision about your care
arrangements must be made by you. In addition, the quality of a
particular provider must be solely determined and monitored by you.
Information provided to you about a particular provider does not
imply and is in no way an endorsement of that particular provider
by Solutions for Caregivers. The information on and the selection
of a particular provider has been supplied by the provider and is
subject to change without written consent of Solutions for
Caregivers. NurseLine should not be used for emergency or urgent
care needs. In an emergency, call 911 or go to the nearest
emergency room. The information provided through this service is
for informational purposes only. The nurses cannot diagnose
problems or recommend treatment and are not a substitute for your
doctor’s care. Your health information is kept confidential in
accordance with the law. Access to this service is subject to terms
of use. Refer to your Evidence of Coverage for more details.
Consult a health care professional before beginning any exercise
program. Tivity Health and SilverSneakers are registered trademarks
or trademarks of Tivity Health, Inc., and/or its subsidiaries
and/or affiliates in the USA and/or other countries. ©2018. All
rights reserved.
15
The company does not treat members differently because of sex, age,
race, color, disability or national origin. If you think you were
treated unfairly because of your sex, age, race, color, disability
or national origin, you can send a complaint to the Civil Rights
Coordinator. Online: UHC_Civil_Rights@uhc.com Mail: Civil Rights
Coordinator. UnitedHealthcare Civil Rights Grievance. P.O. Box
30608 Salt Lake City, UTAH 84130 You must send the complaint within
60 days of when you found out about it. A decision will be sent to
you within 30 days. If you disagree with the decision, you have 15
days to ask us to look at it again. If you need help with your
complaint, please call the member toll-free phone number listed in
the front of this booklet. You can also file a complaint with the
U.S. Dept. of Health and Human Services. Online:
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf Complaint forms are
available at http://www.hhs.gov/ocr/office/file/index.html. Phone:
Toll-free 1-800-368-1019, 800-537-7697 (TDD) Mail: U.S. Dept. of
Health and Human Services. 200 Independence Avenue, SW Room 509F,
HHH Building Washington, D.C. 20201 We provide free services to
help you communicate with us. Such as, letters in other languages
or large print. Or, you can ask for an interpreter. To ask for
help, please call the member toll-free phone number listed in the
front of this booklet. ATENCIÓN: Si habla español (Spanish), hay
servicios de asistencia de idiomas, sin cargo, a su disposición.
Llame al número de teléfono gratuito que aparece en la portada de
esta guía. (Chinese) XIN LU Ý: Nu quý v nói ting Vit (Vietnamese),
quý v s c cung cp dch v tr giúp v ngôn ng min phí. Xin vui lòng gi
s in thoi min phí dành cho hi viên trên trang bìa ca tp sách này. :
(Korean) .
. PAUNAWA: Kung nagsasalita ka ng Tagalog (Tagalog), may makukuha
kang mga libreng serbisyo ng tulong sa wika. Pakitawagan ang
toll-free na numero ng telepono na nakalista sa harapan ng booklet
na ito. : , (Russian). , .
. )Arabic( : .
16
ATANSYON: Si w pale Kreyòl ayisyen (Haitian Creole), ou kapab
benefisye sèvis ki gratis pou ede w nan lang pa w. Tanpri rele
nimewo telefòn gratis pou manm yo ki sou kouvèti ti liv sa a.
ATTENTION : Si vous parlez français (French), des services d’aide
linguistique vous sont proposés gratuitement. Veuillez appeler le
numéro de téléphone sans frais pour les affiliés figurant au début
de ce guide. UWAGA: Jeeli mówisz po polsku (Polish), udostpnilimy
darmowe usugi tumacza. Prosimy zadzwoni pod bezpatny czonkowski
numer telefonu podany na okadce tej broszury. ATENÇÃO: Se você fala
português (Portuguese), contate o serviço de assistência de idiomas
gratuito. Ligue gratuitamente para o número do membro encontrado na
frente deste folheto. ATTENZIONE: in caso la lingua parlata sia
l’italiano (Italian), sono disponibili servizi di assistenza
linguistica gratuiti. Si prega di chiamare il numero verde per i
membri indicato all'inizio di questo libretto. ACHTUNG: Falls Sie
Deutsch (German) sprechen, stehen Ihnen kostenlos sprachliche
Hilfsdienstleistungen zur Verfügung. Bitte rufen Sie die
gebührenfreie Rufnummer für Mitglieder auf der Vorderseite dieser
Broschüre an. (Japanese)
. )Farsi( :
.
: (Hindi) , , : - CEEB TOOM: Yog koj hais Lus Hmoob (Hmong), muaj
kev pab txhais lus pub dawb rau koj. Thov hu tus tswv cuab xov tooj
hu dawb teev nyob ntawm sab xub ntiag ntawm phau ntawv no.
(Khmer) PAKDAAR: Nu saritaem ti Ilocano (Ilocano), ti serbisyo para
ti baddang ti lengguahe nga awanan bayadna, ket sidadaan para
kenyam. Pakitawagan iti miyembro toll-free nga number nga nakasurat
iti sango ti libro. DÍÍ BAA'ÁKONÍNÍZIN: Diné (Navajo) bizaad bee
yániti'go, saad bee áka'anída'awo'ígíí, t'áá jíík'eh, bee
ná'ahóót'i'. T'áá shdí díí naaltsoos bidáahgi t'áá jiik'eh
naaltsoos báha'dít'éhígíí béésh bee hane'í biká'ígíí bee hodíilnih.
OGOW: Haddii aad ku hadasho Soomaali (Somali), adeegyada taageerada
luqadda, oo bilaash ah, ayaad heli kartaa. Fadlan wac lambarka
xubinta ee telefonka bilaashka ah ee ku qoran xagga hore ee
buugyaraha.
UHEX20MP4490583_000
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Y0066_190516_092901_M
Drug List
This is a partial alphabetical list of prescription drugs covered
by the plan as of August 1, 2019.
This list can change throughout the year. Call us or go online for
the most complete, up-to-date
information. Our phone number and website are listed on the back
cover of this book.
· Brand name drugs are in bold type. Generic drugs are in plain
type
· Covered drugs are placed in tiers. Each tier has a different
cost
Tier 1: Preferred generic
Tier 2: Preferred brand
Tier 3: Non-preferred drug
Tier 4: Specialty tier
· Each tier has a copay or coinsurance amount
· See the Summary of Benefits in this book to find out what you’ll
pay for these drugs
· Some drugs have coverage requirements, such as Prior
Authorization or Step Therapy. If
your drug has any coverage rules or limits, there will be code(s)
in the list. The codes and
what they mean are shown below
PA
Prior
authorization
The plan needs more information from your doctor to make sure the
drug
is being used correctly for a medical condition covered by
Medicare. If you
don’t get prior approval, it may not be covered.
QL
Quantity limits
The plan only covers a certain amount of this drug for 1 copay.
Limits help
make sure the drug is used safely. If your doctor prescribes more
than the
limit, you or your doctor can ask the plan to cover the additional
quantity.
ST
Step therapy
You may need to try lower-cost drugs that treat the same condition
before
the plan will cover your drug. If you have tried other drugs or
your doctor
thinks they are not right for you, you or your doctor can ask the
plan for
coverage.
B/D
Medicare Part B
or Part D
Depending on how this drug is used, it may be covered by Medicare
Part B
or Part D. Your doctor may need to give the plan more information
about
how this drug will be used to make sure it’s covered
correctly.
HRM
High-risk
medication
This drug is known as a high-risk medication (HRM) for patients 65
years
and older. This drug may cause side effects if taken on a regular
basis. We
suggest you talk with your doctor to see if an alternative drug is
available to
treat your condition.
T1 = Tier 1 T2 = Tier 2 T3 = Tier 3 T4 = Tier 4
18
LA
Limited access
The FDA only lets certain facilities or doctors give out this drug.
It may
require extra handling, doctor coordination or patient
education.
MME
Morphine
milligram
equivalent
Additional quantity limits may apply across all drugs in the opioid
class
used for the treatment of pain. This additional limit is called a
cumulative
morphine milligram equivalent (MME), and is designed to monitor
safe
dosing levels of opioids for individuals who may be taking more
than 1
opioid drug for pain management. If your doctor prescribes more
than this
amount or thinks the limit is not right for your situation, you or
your doctor
can ask the plan to cover the additional quantity.
7D
7-Day limit
An opioid drug used for the treatment of acute pain may be limited
to a 7-
day supply for members with no recent history of opioid use. This
limit is
intended to minimize long-term opioid use. For members who are new
to
the plan, and have a recent history of using opioids, the limit may
be
overridden by having the pharmacy contact the plan.
DL
Dispensing limit
Dispensing limits apply to this drug. This drug is limited to a 1
month
supply per prescription.
Release),T1
Acetazolamide (Oral Tablet),T1
Release 12 Hour),T1
Acyclovir (Oral Capsule),T1
Acyclovir (Oral Tablet),T1
Adacel (Intramuscular Suspension),T2
Breath Activated),T1 - QL
Aggrenox (Oral Capsule Extended Release 12
Hour),T3 - QL
24 Hour),T1
QL
Amiloride HCl (Oral Tablet),T1
Amiodarone HCl (Oral Tablet),T1
19
Amlodipine Besylate (Oral Tablet),T1
Amlodipine-Benazepril (Oral Capsule),T1 - QL
Ammonium Lactate (External Cream),T1
Ammonium Lactate (External Lotion),T1
Anagrelide HCl (Oral Capsule),T1
Breath Activated),T2 - QL
Hour),T2 - QL
0.3ML Injection Solution Prefilled
40MCG/0.4ML Injection Solution Prefilled
Solution, 40MCG/ML Injection Solution),T3 -
Breath Activated),T2 - QL
Release 12 Hour),T1 - QL
Atenolol (Oral Tablet),T1
Atovaquone-Proguanil HCl (Oral Tablet),T1
Atripla (Oral Tablet),T4 - QL
Auryxia (Oral Tablet),T4 - PA
Avonex (30MCG Intramuscular Kit),T4
Avonex Pen (Intramuscular Auto-Injector
Solution),T1
Baclofen (Oral Tablet),T1
This is a partial alphabetical list. This is not a complete list of
the prescription drugs we cover.
T1 = Tier 1 T2 = Tier 2 T3 = Tier 3 T4 = Tier 4
20
Benazepril-Hydrochlorothiazide (Oral Tablet),T1 -
Bepreve (Ophthalmic Solution),T3
Betaseron (Subcutaneous Kit),T4
Activated),T2 - QL
Particles),T1
Release),T1
Extended Release 24 Hour),T3
Release 12 Hour Smoking-Deterrent),T1
12 Hour),T1
Release 24 Hour),T1
DL; QL
Pen-Injector),T3 - ST; QL
Pen-Injector),T3 - ST; QL
Capsule),T1
Tablet),T1
Carafate (Oral Suspension),T3
This is a partial alphabetical list. This is not a complete list of
the prescription drugs we cover.
Bold type = Brand name drug Plain type = Generic drug
21
Release),T1
Release, 500MG Oral Tablet Immediate
Release, 750MG Oral Tablet Immediate
Release),T1
PA; HRM
Release),T1
Clozapine (Oral Tablet),T1
Equivalent Mitigare),T2 - QL
Colcrys),T2 - QL
Prefilled Syringe),T4 - PA; LA
Cosopt PF (Ophthalmic Solution),T3
Particles),T2
D
Desmopressin Acetate (Oral Tablet),T1
This is a partial alphabetical list. This is not a complete list of
the prescription drugs we cover.
T1 = Tier 1 T2 = Tier 2 T3 = Tier 3 T4 = Tier 4
22
QL
Release),T1
Digoxin (125MCG Oral Tablet),T1 - HRM; QL
Digoxin (250MCG Oral Tablet),T1 - PA; HRM
Dihydroergotamine Mesylate (Nasal Solution),T1
Release 12 Hour),T1
Extended Release 24 Hour, 420MG Oral
Capsule Extended Release 24 Hour),T1
Diltiazem HCl ER Coated Beads (120MG Oral
Capsule Extended Release 24 Hour, 180MG
Oral Capsule Extended Release 24 Hour,
240MG Oral Capsule Extended Release 24
Hour, 300MG Oral Capsule Extended Release
24 Hour),T1
Release Sprinkle),T1
Release),T1
Release 24 Hour),T1
Tablet),T1 - QL
QL
Immediate Release),T1
Duloxetine HCl (20MG Oral Capsule Delayed
Release Particles, 30MG Oral Capsule Delayed
Release Particles, 60MG Oral Capsule Delayed
Release Particles),T1 - QL
Durezol (Ophthalmic Emulsion),T2
Dutasteride (Oral Capsule),T1
Dymista (Nasal Suspension),T3
7D; MME; DL; QL
Enalapril-Hydrochlorothiazide (Oral Tablet),T1 -
Epclusa (Oral Tablet),T4 - PA; QL
This is a partial alphabetical list. This is not a complete list of
the prescription drugs we cover.
Bold type = Brand name drug Plain type = Generic drug
23
Hour),T3
PA; HRM; QL
HRM; QL
Ethosuximide (Oral Capsule),T1
Extavia (Subcutaneous Kit),T4
Ezetimibe (Oral Tablet),T1
Tablet),T1
Fenofibrate (145MG Oral Tablet, 160MG Oral
Tablet, 48MG Oral Tablet, 54MG Oral
Tablet),T1
Hour, 12MCG/HR Transdermal Patch 72 Hour,
25MCG/HR Transdermal Patch 72 Hour,
50MCG/HR Transdermal Patch 72 Hour,
75MCG/HR Transdermal Patch 72 Hour),T1 -
7D; MME; DL; QL
Proscar),T1
Breath Activated),T2
Fluconazole (Oral Tablet),T1
Glatiramer Acetate (Subcutaneous Solution
Glipizide ER (Oral Tablet Extended Release 24
This is a partial alphabetical list. This is not a complete list of
the prescription drugs we cover.
T1 = Tier 1 T2 = Tier 2 T3 = Tier 3 T4 = Tier 4
24
Humalog (Subcutaneous Solution
Suspension Pen-Injector),T2
Suspension Pen-Injector),T2
0.4ML Subcutaneous Prefilled Syringe
Tablet),T1 - 7D; MME; DL; QL
Hydromorphone HCl (Oral Tablet Immediate
Release),T1 - 7D; MME; DL; QL
Hydroxychloroquine Sulfate (Oral Tablet),T1
Hysingla ER (Oral Tablet ER 24 Hour Abuse-
Deterrent),T2 - 7D; MME; DL; QL
I
Tablet, 800MG Oral Tablet),T1
Imiquimod (5% External Cream),T1
Imvexxy Maintenance Pack (Vaginal Insert),T2
- PA; QL
QL
Breath Activated),T2 - QL
Tablet),T4 - QL
- QL
24 Hour),T2 - QL
D,PA
Irbesartan (Oral Tablet),T1 - QL
This is a partial alphabetical list. This is not a complete list of
the prescription drugs we cover.
Bold type = Brand name drug Plain type = Generic drug
25
Release),T1
Release),T1
Release),T1
Release 24 Hour),T1
Ivermectin (Oral Tablet),T1
QL
Hour),T2 - QL
24 Hour),T2 - QL
Jublia (External Solution),T3
Packet),T4 - PA; LA
Ketoconazole (External Cream),T1 - QL
HRM
Release),T1
24 Hour),T3 - QL
L
Tablet),T1 - QL
Lantus (Subcutaneous Solution),T2
Injector),T2
Leflunomide (Oral Tablet),T1
Letrozole (Oral Tablet),T1
Levofloxacin (Oral Tablet),T1
This is a partial alphabetical list. This is not a complete list of
the prescription drugs we cover.
T1 = Tier 1 T2 = Tier 2 T3 = Tier 3 T4 = Tier 4
26
Lidocaine (5% External Patch),T1 - PA; QL
Lidocaine HCl (4% External Solution),T1
Lidocaine Viscous (2% Mouth/Throat
Release),T1
Lotemax (Ophthalmic Gel),T3
Lotemax (Ophthalmic Ointment),T3
Lotemax (Ophthalmic Suspension),T3
Medroxyprogesterone Acetate (Intramuscular
Tablet),T1 - PA; QL
Release 24 Hour),T1 - PA; QL
Mercaptopurine (Oral Tablet),T1
Meropenem (Intravenous Solution
Release) (Generic Lialda),T1 - QL
Release),T1 - QL
24 Hour) (Generic Glucophage XR),T1 - QL
Methadone HCl (Oral Tablet),T1 - 7D; MME; DL;
QL
QL
Release) (Generic Ritalin),T1 - QL
Metoclopramide HCl (Oral Tablet),T1
This is a partial alphabetical list. This is not a complete list of
the prescription drugs we cover.
Bold type = Brand name drug Plain type = Generic drug
27
Release 24 Hour),T1
Oral Tablet, 50MG Oral Tablet),T1
Metronidazole (External Cream),T1
Metronidazole (External Gel),T1
Metronidazole (External Lotion),T1
Metronidazole (Oral Capsule),T1
Metronidazole (Oral Tablet),T1
Release),T1
Misoprostol (Oral Tablet),T1
Mometasone Furoate (Nasal Suspension),T1
Morphine Sulfate ER (100MG Oral Capsule
Extended Release 24 Hour, 10MG Oral Capsule
Extended Release 24 Hour, 20MG Oral Capsule
Extended Release 24 Hour, 30MG Oral Capsule
Extended Release 24 Hour, 50MG Oral Capsule
Extended Release 24 Hour, 60MG Oral Capsule
Extended Release 24 Hour, 80MG Oral Capsule
Extended Release 24 Hour),T1 - 7D; MME; DL;
QL
DL; QL
- 7D; MME; DL; QL
Hour),T2
N
Syringe),T1
Pack),T2 - PA; QL
Hour),T2 - PA; QL
Narcan (Nasal Liquid),T2
Neulasta (Subcutaneous Solution Prefilled
Extended Release),T1
Macrodantin),T1 - HRM
Nitroglycerin (Tablet Sublingual),T1
Nitrostat (Tablet Sublingual),T3
Nizatidine (Oral Capsule),T1
This is a partial alphabetical list. This is not a complete list of
the prescription drugs we cover.
T1 = Tier 1 T2 = Tier 2 T3 = Tier 3 T4 = Tier 4
28
Nortriptyline HCl (Oral Capsule),T1 - PA; HRM
Nucynta ER (Oral Tablet Extended Release 12
Hour),T2 - 7D; MME; DL; QL
Nuedexta (Oral Capsule),T3 - PA
Solution),T4 - PA
Solution),T4 - PA
Solution),T4 - PA
Olmesartan Medoxomil-HCTZ (Oral Tablet),T1 -
(Generic Lovaza),T1
Release),T1 - QL
Release),T1
B/D,PA
Release),T3 - PA; LA
Release, 1MG Oral Tablet Extended Release,
2.5MG Oral Tablet Extended Release, 5MG
Oral Tablet Extended Release),T4 - PA; LA
Oseltamivir Phosphate (Oral Capsule),T1
Oxcarbazepine (Oral Tablet),T1
Deterrent),T2 - 7D; MME; DL; QL
Oxybutynin Chloride ER (Oral Tablet Extended
Release 24 Hour),T1
DL; QL
Oxycodone-Acetaminophen (Oral Tablet),T1 - 7D;
Release),T1 - QL
Perforomist (Inhalation Nebulization
Solution),T3 - B/D,PA; QL
Permethrin (External Cream),T1
Phenytoin Sodium Extended (Oral Capsule),T1
This is a partial alphabetical list. This is not a complete list of
the prescription drugs we cover.
Bold type = Brand name drug Plain type = Generic drug
29
Pomalyst (Oral Capsule),T4 - PA
Release),T1
Release),T1
Release),T1
Pramipexole Dihydrochloride (Oral Tablet
Prazosin HCl (Oral Capsule),T1
Premarin (Vaginal Cream),T2
Tablet),T3 - QL
Tablet),T4 - QL
Breath Activated),T2
Release 24 Hour),T1
Propylthiouracil (Oral Tablet),T1
Immediate Release),T1
Release),T1 - QL
Quinapril-Hydrochlorothiazide (Oral Tablet),T1 -
Tablet),T1
Restasis (Ophthalmic Emulsion),T2 - QL
Retacrit (10000UNIT/ML Injection Solution,
2000UNIT/ML Injection Solution, 3000UNIT/
This is a partial alphabetical list. This is not a complete list of
the prescription drugs we cover.
T1 = Tier 1 T2 = Tier 2 T3 = Tier 3 T4 = Tier 4
30
Reyataz (Oral Capsule),T4 - QL
Reyataz (Oral Packet),T4 - QL
Dispersible),T1 - QL
Release),T1
S
Tablet, 75MG Oral Tablet),T4 - QL
Serevent Diskus (Inhalation Aerosol Powder
Breath Activated),T2 - QL
Renvela),T1
Revatio),T1 - PA
Sotalol HCl (Oral Tablet),T1
Spiriva HandiHaler (Inhalation Capsule),T2 -
Suprax (100MG/5ML Oral Suspension
Reconstituted, 200MG/5ML Oral Suspension
Suprax (Oral Tablet Chewable),T2
This is a partial alphabetical list. This is not a complete list of
the prescription drugs we cover.
Bold type = Brand name drug Plain type = Generic drug
31
Symbicort (Inhalation Aerosol),T2 - QL
Injector),T4 - PA
Injector),T4 - PA
QL
Hour),T2 - QL
LA; QL
Capsule),T1 - HRM; QL
QL
Gel), Testosterone Pump (1% Transdermal Gel,
1.62% Transdermal Gel),T1
Testosterone Cypionate (Intramuscular
Release 12 Hour, 200MG Oral Tablet Extended
Release 12 Hour, 300MG Oral Tablet Extended
Release 12 Hour),T1
24 Hour),T1
Timoptic),T1
(Ophthalmic Solution) (Generic Timoptic-XE),T1
Timoptic Ocudose (Ophthalmic Solution),T3
Tablet),T4 - QL
Release),T1
Injector),T2
Tranexamic Acid (Oral Tablet),T1
Transderm-Scop (1.5MG) (Transdermal Patch
72 Hour),T3 - PA; HRM
Tablet, 50MG Oral Tablet),T1
Breath Activated),T2 - QL
Tretinoin (External Cream),T1 - PA
This is a partial alphabetical list. This is not a complete list of
the prescription drugs we cover.
T1 = Tier 1 T2 = Tier 2 T3 = Tier 3 T4 = Tier 4
32
Trintellix (Oral Tablet),T3
Valproic Acid (Oral Capsule),T1
Valsartan (Oral Tablet),T1 - QL
PA
Release),T1
Release 24 Hour),T1
Release),T1
Vyvanse (Oral Capsule),T3
Activated) (Generic Advair),T1 - QL
Hour),T3 - ST; QL
Xolair (Subcutaneous Solution Prefilled
Deterrent),T3 - ST; 7D; MME; DL; QL
Xtandi (Oral Capsule),T4 - PA; LA
Z
Particles),T2
Zioptan (Ophthalmic Solution),T3
This is a partial alphabetical list. This is not a complete list of
the prescription drugs we cover.
Bold type = Brand name drug Plain type = Generic drug
33
Release),T1 - PA; HRM; QL
Zonisamide (Oral Capsule),T1
This is a partial alphabetical list. This is not a complete list of
the prescription drugs we cover.
T1 = Tier 1 T2 = Tier 2 T3 = Tier 3 T4 = Tier 4
OVCT20Un4476063_000
34
Additional prescription drug coverage
Your plan includes extra coverage for certain drugs and supplies as
shown below.
This is not a complete list of prescription drugs and supplies
covered by our plan. For a complete
list, please call Customer Service toll-free at 1-888-803-9217, TTY
711, 8 a.m. - 8 p.m. local time,
Monday – Friday.
Lower-cost Medicare prescription drugs and supplies
Your plan covers some of your Medicare prescription drugs and
supplies at a lower drug copay
than in your drug list (formulary).
The amount you pay for these prescription drugs and supplies does
apply to your Medicare
prescription drug out-of-pocket costs. Payments for these
prescription drugs (made by you or the
plan) are treated the same as payments made for drugs in your
plan’s drug list (formulary).1
These drugs and supplies are part of your Medicare prescription
drug coverage.1
$0 Copay Birth Control
$0 Copay Blood Glucose Meters, Test Strips
and Lancets
ACCU-CHEK® Guide Meter & Test Strip
ACCU-CHEK® Guide Me Meter & Test Strip
ACCU-CHEK® Compact Plus Test Strips
ACCU-CHEK® SmartView Test Strips
OneTouch® Ultra® Test Strips
Acarbose Tablet
36
The drugs listed below to treat asthma or COPD, heart disease/heart
failure, hypertension and
cholesterol are available at a reduced copay. See your Evidence of
Coverage for information about
copays.
Disease (COPD)
Accolate Tablets
Alvesco Inhaler
Aminophylline Injection
Anoro Ellipta
Arcapta Neohaler
Armonair Respiclick
Arnuity Ellipta
Tablet
Fenoglide Tablet
Fibricor Tablet
Flolipid Suspension
Acetazolamide ER Capsule, Injection and Tablet
Aldactazide Tablet
Aldactone Tablet
Amiloride Tablet
Amiloride/Hydrochlorothiazide Tablet
Amlodipine/Atorvastatin Tablet
Diuril Suspension
Dyazide Capsule
Dyrenium Capsule
Edecrin Tablet
Eplerenone Tablet
Hydrochlorothiazide Capsule & Tablet
Cardura Tablet
Tablet
Innopran XL Capsule
Metoprolol/Hydrochlorothiazide Tablet
& Tablet
Tablet
40
Lower-cost non-Medicare prescription drugs and supplies
These prescription drugs and supplies are covered in addition to
the drugs in your plan’s drug list
(formulary).2
The amount you pay for these additional prescription drugs and
supplies does not apply to your
Medicare Part D out-of-pocket costs. Payments made for these drugs
and supplies (made by you
or the plan) are treated differently from payments made for the
drugs in your plan’s drug list
(formulary).
If you get Extra Help from Medicare to pay for your drugs, it will
not apply to these additional
covered drugs or supplies.
Drug Name $0 Copay
1Information about the appeals and grievance process for these
prescription drugs and supplies
can be found in your Evidence of Coverage.
2This non-Medicare drug coverage is in addition to your Medicare
drug coverage. Unlike your
Medicare drug coverage, you cannot file a Medicare appeal or
grievance for non-Medicare drug
coverage. If you have questions, please call Customer Service
toll-free at 1-888-803-9217, TTY
711, 8 a.m. – 8 p.m. local time, Monday – Friday.
41
Bonus Drug List
The Plan offers a bonus drug list. The prescription drugs on this
list are covered in addition to the
drugs on the plan’s drug list (formulary).
The drug tier for each prescription drug is shown on the
list.
Although you pay the same copay for these drugs as shown in the
Summary of Benefits and
Evidence of Coverage, the amount you pay for these additional
prescription drugs does not apply
to your Medicare Part D out-of-pocket costs. Payments for these
additional prescription drugs
(made by you or the plan) are treated differently from payments
made for other prescription drugs.
Coverage for the prescription drugs on the bonus drug list is in
addition to your Part D drug
coverage. Unlike your Part D drug coverage, you are unable to file
a Medicare appeal or grievance
for drugs on the bonus drug list. If you have questions, please
call Customer Service toll-free at
1-888-803-9217, TTY 711, 8 a.m. – 8 p.m. local time, Monday –
Friday.
If you get Extra Help from Medicare to pay for your prescription
drugs, it will not apply to the drugs
on this bonus drug list.
This is not a complete list of the prescription drugs available to
you or the restrictions and
limitations that may apply through the bonus drug list. If your
drug has any coverage rules or limits,
there will be code(s) in the “Coverage Rules or Limits on use”
column of the chart. The codes and
what they mean are shown below. If you have questions about drug
coverage, please call Customer
Service toll-free at 1-888-803-9217, TTY 711, 8 a.m. – 8 p.m. local
time, Monday – Friday.
QL
Quantity limits
The plan only covers a certain amount of this drug for one copay
or
over a certain number of days. These limits may be in place
to
ensure safe and effective use of the drug.
DL
Dispensing limit
Dispensing limits apply to this drug. This drug is limited to a
one
month supply per prescription.
Drug Tier Coverage Rules or Limits on use
Analgesics - drugs to treat pain, inflammation, and muscle and
joint conditions
Inflammation
Phentermine 1 QL (maximum of 1 capsule/tablet
per day)
Y0066_190620_080130_C
42
Anticoagulants - drugs to prevent clotting
Heparin Lock Flush 1
Dry, Itchy Scalp
Sulfacetamide Sodium w/Sulfur in Urea
Emulsion 10-5% 1
Gastrointestinal agents - drugs to treat bowel, intestine and
stomach conditions
Hemorrhoids
Lidocaine/Hydrocortisone Acetate 1
Genitourinary agents - drugs to treat bladder, genital and kidney
conditions
Erectile Dysfunction
month)
Sildenafil (25 mg, 50 mg, 100 mg) 1 QL (maximum of 6 tablets
per
month)
month)
month)
43
Addyi 3 QL (maximum of 1 tablet per day)
Urinary Tract Infection
Thyroid Supplement
Potassium Supplement
Effer-K 3
Folic Acid 1 mg (Rx only) 1
Folic Acid-Vitamin B6-Vitamin B12 Tablet
2.5-25-1 mg 1
Nephro-Vite Rx 3
Vitamin D 50,000 unit (Rx only) 1
Respiratory tract agents - drugs to treat allergies, cough, cold
and lung conditions
Cough and Cold
Brompheniramine/Pseudoephedrine/
44
Hydrocodone Polst/Chlorpheniramine ER Susp
Hydrocodone/Homatropine 1 DL
BDL: BDL U
45
This information is not a complete description of benefits. Contact
the plan for more information.
Limitations, copayments, and restrictions may apply.
Benefits and/or copayments/coinsurance may change each plan/benefit
year.
The drug list may change at any time. You will receive notice when
necessary.
Plans are insured through UnitedHealthcare Insurance Company or one
of its affiliated companies,
a Medicare Advantage organization with a Medicare contract.
Enrollment in the plan depends on
the plan’s contract renewal with Medicare.
UHEX20PP4583885_000
46
NOTES
Y0066_GRPCov_4484187_2020_C This is an advertisement.
UHEX20PP4492325_000
1-888-803-9217, TTY 711 8 a.m. - 8 p.m. local time, Monday -
Friday
Learn more at www.UHCRetiree.com/CT
SU ST